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Home My WebLink About2025-26ch.N0.6'// Lrcr,NSE FF,t sts} BHHLI-23- l8W TO\I'N OF YAR}IOUTH BOARD OF HEALTH 2025/2026 HANDLING -{\D STORACE O}-TOXIC OR HAZARDOLIS M.\TERIAI-S LICENSE APPLICATIOn. COMPLETE THIS APPLICATION AND RETURN IT WITH T BY JUNE 30, 2025 E CO]\{PLETE ALL UESTI N NAME OF BUSINESS BUSINESS TEL. # HEAITH E E LTETNSlree-i MAILING ADDRESS 0 -k Qtnfrrt{ g ? Con*.s+,. r,r TELEPHONE #5n8'3tl{-q66g fr t tFrt:0atL RFOI IRFD OWNER NAME HOME ADDR[rSS c t CORPORATION NAME (IF APPLICABLE) TEL. # CORPORATION ADDRESS MAILING ADDRESS rer+Er8-ttE-9dl68 LICENSES RUN ANNUALLY FROM JULY I TO JT]NE 30. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLNE ]0. FAILURE TO DO SO WILL RESULT TN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S)ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance ofyour permits. Please check appropriately ifpaid: yes-- no_ r,la- Under Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal ofany license or permit to operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must complete the enclosed workers Compensation Affidavit. If nol appIicablc. plcasc cxplain REGISTRATION FORM SIGNED AND COMPLETED YN ALL SAFETY DATA SHEETS ONFILE ,.. yN ANY NEW CHEMICALS MUST BE PRE-APPROVED BY THE HEALTII DEPARTMf,NT. RENEWAL APPLICATION ,"- NEW APPLICATION- APPLICANT'S SIGNATURE BUSTNESSADDRESSTNYARMOUTH 6b? fn/\h slreet q+. A8 rrif. A-a EMAIL ADDRESS luN z 4 ?0?5 RIOT]I RED MANAGER/CONTACT PERSON TAX ID (FEIN OR SSN)BrcUlruD D^rE,6'l+25 The Commonwealth of Massachusetts Department of Industial Accidents Office of I nvestigatio ns Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02IlI-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ,71 Business/Organization Name:C+ Address:n Citylstate/Zip:W. la(n^ofl^. {nn- (l,6)3 Phone #g1 q6al Are you an employer? Check tfue appropriate box: tE t urn a employer wirh € employees (full and or oart-time) * Z.W I a^a sole proprietor or partnershrp and have no J 4 employees working for me in any capacity. INo workers' comp. insurance required] We are a corporation and its officcrs have exercised their right of exemption per c. 152, $l(4), and we have no employees. [No workers' comp. insurance required]** We are a non-profit organization, staffed by voluntecrs, with no employees. [No workers' comp. insurance req.] Business Type (required) 5. ! Retail 6 7 Restaurant,/Bar/Eating Establishment Office and/ot Sales (incl. real estate, auto, etc.) 8. ! Non-profit 9. ! Entertainment l0[Manufacturing ll Health Care Othert2 *Any applicalt thal checks box # I must also fill out lhe section below showing their workers' compensation policy information. **lf the corporate officers have exempted themselves, but the corpomtion has other employees. a workers' compensation policy is required and such an organization should check box #1. I tm an employer that is providing workers' compensalion insurance for my employees. Below is the policy infomation. Insurance Company Name City/5121s17ir'. Policy f or Self-ins. Lic, l Expiration Date:- Attach a cop)' of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to securc covcrage as rcquircd under $ 25A of MGL c. I 52 can lead to the imposition of criminal pcnalties of a fitre up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised thal a copy ofthis statement may be forwarded to the Office of lnvestigations of the DIA for insurance coverage verification. I do hereby under the pal s of perjury that lhe information provided above is true ond correcl Date C Phone #sA-VlS-q621 Olficirl use only. Do not wite i this area, to be completed by ci,r* or town ollicial Cit-v or Town: Permit/License #- 5[ Selectmen's Oflice 6. !Other Phone #: 3flCiry/Town Clerk 4.nLicensing Board Contact Person: lssuing Authority (check one): I flBoard of Health 2.E Building Department Applicant Information Please Print Lesiblv Insurer's Address: www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all cmployers to providc workcrs' compensation for their employees Pursuant to this stai)te, al employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enlerprise. and including the legal representatives of a deceased employer, or the receiver or trustee ofan individual, partnership. association or other lcgal entity, employing employees. Howevcr, Ihc owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant ofthe dwelling house of another who employs persons to do maintenance. construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such cmploymcnt be deemed to be an employcr." MGL chapter 152, g25C(6) also states that "every stat€ or local licensing agency shall withhold the issuanc€ or renewal of a liccnse or permit to operate a business or to construcl buildings in the commonwcalth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter I 52, g25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enler into any contracl for the performance ofpublic work until acceptable cvidcnce ofcompliance with lhe insurancc requirements of this chapter have been presented to thc contracting authority." City or Town Olficials Please be sure that thc affidavit is complcte and printed lcgibly. The Departmenl has provided a space at the bottom of thc affidavit for you to fill out in thc evcnt thc OIIice of Invcstigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given ycar, necd only submit onc affidavit indicating current policy information (ifnecessary). A copy ofthe affidavit that has becn officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid alfidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial vcnture (i.e. a dog licensc or pcrmit to bum leavcs etc.) said person is NOT required to complete this affidavit. The Office of Investigalions would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Offi ce of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 021I l-1750 Tel. (857) 321-7406 or l-877-MASSAFE Fax (617) 727-7749 Form Revised 7/201s WWW.maSS.gOV/dia Applicants Please till out the workers' compensation atlidavit completely, by checking the boxes that apply to your situation and, if necessary. supply your insurance company's name, address and phone number along with a certificate ofinsurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the mcmbers or partners, are not required to carr)'workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this aflidavit may be submitted to the Departrnent of lndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department oflndustrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on lhe appropriate line.